SITE INFORMATION AND CORRESPONDENCE

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- SERVICE REQUEST .x r_ RVREO) Revised-8/M FACILITY ID # RECORD ID N TV010E W I L T T Y NAME Yl Y GL'?M4"P Y - !l SITE ADDRESS CITYCA . ZIP /�,�� I ' OLINFR/OPERATOR I�L e O A BILLING PARTY Y / N 4 , DBA �✓1i/Tl �� - -- ' PHONE 01 ( ) F ADDRESS PHONE 02 i ) CITY STATE ZI1P 7,5 -ZWG/ —APR'# Land Use Application N .1 location Code CONTRACTOR and/or SERVICE � I IEL NG PARTY Y 1 N SERVICE REQUESTOR �` � DBA PHONE N1 - - 4 HATLING ADDRESS kpw !r G jef'[/ 1 FAX 0 ( ) CITY G STATE ZI.P BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of seine, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. 1 I also certify that I have prepared this applicat on and that the work to be';performed will be done in accordance with ail SAN JOAOUIN COUNTY Ordinance Codes a tldar St and Federal laws. APPLICANTOS SIGNATURE i i t Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirormental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It is available and at the same time It Is provided to me or my representative. i Nature of Service Request: , Service Cock Assigned to ia�l np oy v` - E 1 ee N Date / / Date Service Completed / / Further Action Required: I Y / N PROGRAM ELEMENT Oni Fee Amount Amount Paid Date of Payment Payment Type i Receipt N Check N Recvd By I RENS / / SUPV �/ / ACCT / / UNIT CLK 1 ,